Systems and methods for protecting the cerebral vasculature

ABSTRACT

Vascular filters and deflectors and methods for filtering bodily fluids. A blood filtering assembly can capture embolic material dislodged or generated during an endovascular procedure to inhibit or prevent the material from entering the cerebral vasculature. A blood deflecting assembly can deflect embolic material dislodged or generated during an endovascular procedure to inhibit or prevent the material from entering the cerebral vasculature.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority under 35 U.S.C. § 119 toU.S. Provisional Application Ser. No. 62/577,870, filed Oct. 27, 2017,the entirety of which is incorporated herein by reference.

TECHNICAL FIELD

In general, the present disclosure relates to medical devices forfiltering blood. And, more particularly, in certain embodiments, to amethod and a system of filters and deflectors for protecting thecerebral arteries from emboli, debris and the like dislodged during anendovascular or cardiac procedure.

BACKGROUND

There are four arteries that carry oxygenated blood to the brain, i.e.,the right and left vertebral arteries, and the right and left commoncarotid arteries. Various procedures conducted on the human body, e.g.,transcatheter aortic valve replacement (TAVR), aortic valvevalvuloplasty, carotid artery stenting, closure of the left atrialappendage, mitral valve annuloplasty, repair or replacement, can causeand/or dislodge materials (whether native or foreign), these dislodgedbodies can travel into one or more of the cerebral arteries resultingin, inter alia, stroke.

There exist devices for protecting one or more cerebral arteries byeither collecting (filters) or deflecting (deflectors) debris. Singlefilters, such as those used during a carotid artery stenting are onesuch device.

Applicants have previously patented a dual filter embolic protectionsystem that protects the right vertebral, and right and left commoncarotid arteries, see e.g., U.S. Pat. No. 9,492,264, the entirety ofwhich is incorporated herein. Other attempts at deflecting debris fromentering one or more cerebral arteries using a deflector placed in theaorta or aortic arch have also been disclosed. Of the known medicaldevices, delivery systems, and methods, each has certain advantages anddisadvantages. There is an ongoing need to provide alternative medicaldevices and methods as well as alternative methods for manufacturing andusing medical devices.

SUMMARY

Certain aspects of the present disclosure address debris, tissue, etc.,that can be dislodged during an endovascular procedure, this debris cantravel toward, into and embolize within the cerebral vasculature leadingto stroke or ischemia in an artery occluded, partially or totally, bythe clot. For example, during a transcatheter aortic valve replacement(TAVR), stenotic material around the valve can be dislodged duringimplantation of the artificial valve. Moreover, atheroma along andwithin the aorta and aortic arch can be dislodged as the TAVR catheteris advanced toward the diseased aortic valve and subsequently withdrawnafter implantation is completed. In addition, pieces of the catheteritself can be stripped away during delivery and implantation. Thesevarious forms of vascular debris, whether native or foreign, can thentravel into one or more cerebral arteries, embolize and cause a stroke,strokes or neurocognitive deficits, for example.

Certain aspects of the present disclosure are intended to address thesepotentially devastating cerebral events by providing a delivery systemcomprised of filters and/or deflectors and/or combinations thereof, tointercept this debris before it can enter any of the cerebral arteries.

Certain aspects of the present disclosure, and its various embodiments,can provide a compound system of filters and/or deflectors forcollecting (and/or deflecting) debris in a manner such that all fourcerebral arteries are protected.

Vascular filters and deflectors and methods for filtering bodily fluidsare disclosed herein. A blood filtering assembly can capture embolicmaterial dislodged or generated during an endovascular procedure toinhibit or prevent the material from entering the cerebral vasculature.A blood deflecting assembly can deflect embolic material dislodged orgenerated during an endovascular procedure to inhibit or prevent thematerial from entering the cerebral vasculature.

In a first example a method of inhibiting embolic material from enteringcerebral vasculature may comprise positioning a guidewire through aright subclavian artery and into a left subclavian artery and tracking adistal portion of a first protection device over the guidewire. Thedistal portion of the first protection device may comprise an outersheath, a first self-expanding filter assembly radially within the outersheath. The method may further comprise at least one of proximallyretracting the outer sheath and distally advancing the self-expandingfilter assembly to deploy the first self-expanding filter assembly fromthe outer sheath in the left subclavian artery upstream of the leftvertebral artery. After deploying the self-expanding filter assembly,the method may further comprise withdrawing the outer sheath from theright subclavian artery and withdrawing the guidewire into an innominateartery and tracking a distal portion of a second protection device overthe guidewire. The distal portion of the second protection device maycomprise a proximal sheath, a proximal self-expanding filter assemblyradially within the proximal sheath, a distal sheath, and a distalself-expanding filter assembly radially within the distal sheath Themethod may further comprise at least one of proximally retracting theproximal sheath and distally advancing the proximal self-expandingfilter assembly to deploy the proximal self-expanding filter assemblyfrom the proximal sheath in the innominate artery, steering the distalsheath into a left common carotid artery, at least one of proximallyretracting the distal sheath and distally advancing the distalself-expanding filter assembly to deploy the distal self-expandingfilter assembly from the distal sheath in the left common carotidartery, and after deploying the proximal and distal self-expandingfilter assemblies, withdrawing the proximal and distal sheaths.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device and the second protection devicemay be inserted into a right radial artery or a right brachial arterythrough a same incision.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise performing an endovascularprocedure, the deployed first, proximal, and distal filter assembliesinhibiting embolic material from entering cerebral vasculature throughthe left vertebral artery, a right common carotid artery, a rightvertebral artery and the left common carotid artery during theendovascular procedure.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise after performing theendovascular procedure, withdrawing the first, proximal, and distalfilter assemblies.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device may further comprise an innermember radially inward of the outer sheath.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise measuring an arterial pressureusing one of the first and second protection devices.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device may further comprise a filter wirecoupled to a proximal end of the first self-expanding filter andextending distally therefrom.

Alternatively or additionally to any of the examples above, in anotherexample, an entirety of a length of the second protection device may betracked over the filter wire.

Alternatively or additionally to any of the examples above, in anotherexample, less than an entirety of a length of the second protectiondevice may be tracked over the filter wire.

Alternatively or additionally to any of the examples above, in anotherexample, the second protection device may further comprise a rapidexchange port.

In another example, a method of inhibiting embolic material fromentering cerebral vasculature may comprise positioning a guidewirethrough a right subclavian artery and into a left subclavian artery andtracking a distal portion of a first protection device over theguidewire. The distal portion of the first protection device maycomprise an outer sheath, an inner member radially inward of the outersheath, the inner member comprising a guidewire lumen, and a firstself-expanding filter assembly radially between the outer sheath and theinner member, the first self-expanding filter assembly having an openingfacing a proximal end of the outer sheath. The method may furthercomprise at least one of proximally retracting the outer sheath anddistally advancing the self-expanding filter assembly to deploy thefirst self-expanding filter assembly from the outer sheath in the leftsubclavian artery upstream of the left vertebral artery, after deployingthe self-expanding filter assembly, withdrawing the outer sheath fromthe right subclavian artery and withdrawing the guidewire into aninnominate artery, and tracking a distal portion of a second protectiondevice over the guidewire. The distal portion of the second protectiondevice may comprise a proximal sheath, a proximal self-expanding filterassembly radially within the proximal sheath, an articulatable distalsheath, and a distal self-expanding filter assembly radially within thedistal sheath. The method may further comprise at least one ofproximally retracting the proximal sheath and distally advancing theproximal self-expanding filter assembly to deploy the proximalself-expanding filter assembly from the proximal sheath in theinnominate artery, steering the distal sheath into a left common carotidartery, at least one of proximally retracting the distal sheath anddistally advancing the distal self-expanding filter assembly to deploythe distal self-expanding filter assembly from the distal sheath in theleft common carotid artery, and after deploying the proximal and distalself-expanding filter assemblies, withdrawing the proximal and distalsheaths.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device and the second protection devicemay be inserted into a right radial artery or a right brachial arterythrough a same incision.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise performing an endovascularprocedure, the deployed first, proximal, and distal filter assembliesinhibiting embolic material from entering cerebral vasculature throughthe left vertebral artery, a right common carotid artery, a rightvertebral artery and the left common carotid artery during theendovascular procedure.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise after performing theendovascular procedure, withdrawing the first, proximal, and distalfilter assemblies.

In another example, a method of inhibiting embolic material fromentering cerebral vasculature may comprise positioning a guidewire in afirst artery, tracking a distal portion of a first protection deviceover the guidewire. The distal portion of the first protection devicemay comprise a proximal sheath, a proximal self-expanding filterassembly radially within the proximal sheath, a distal sheath, a distalself-expanding filter assembly radially within the distal sheath, and anintermediate self-expanding filter assembly radially within the distalsheath. The method may further comprise at least one of proximallyretracting the proximal sheath and distally advancing the proximalself-expanding filter assembly to deploy the proximal self-expandingfilter assembly from the proximal sheath in the first artery, steeringthe distal sheath into a second artery, at least one of proximallyretracting the distal sheath and distally advancing the distalself-expanding filter assembly to deploy the distal self-expandingfilter assembly from the distal sheath in the second artery, steeringthe distal sheath into a third artery, at least one of proximallyretracting the distal sheath and distally advancing the intermediateself-expanding filter assembly to deploy the distal self-expandingfilter assembly from the distal sheath in the third artery, and afterdeploying the proximal, distal, and intermediate self-expanding filterassemblies, withdrawing the proximal and distal sheaths.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device may be inserted into a right radialartery or a right brachial artery.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise performing an endovascularprocedure, the deployed proximal, intermediate, and distalself-expanding filter assemblies inhibiting embolic material fromentering cerebral vasculature through the left vertebral artery, a rightcommon carotid artery, a right vertebral artery and the left commoncarotid artery during the endovascular procedure.

Alternatively or additionally to any of the examples above, in anotherexample, the method may further comprise after performing theendovascular procedure, withdrawing the proximal, intermediate, anddistal filter assemblies.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device may further comprise a tetherextending between the distal self-expanding filter assembly and theintermediate self-expanding filter assembly.

Alternatively or additionally to any of the examples above, in anotherexample, the tether may have a preformed shape configured to guide theintermediate filter assembly towards the third artery.

In another example, an embolic protection system for isolating thecerebral vasculature may comprise a first protection device having aproximal portion configured to remain outside the body and a distalportion and a second protection device having a proximal portionconfigured to remain outside the body and a distal portion. The distalportion of the first protection device may comprise an outer sheath anda first self-expanding filter assembly radially within the outer sheath.The distal portion of the second protection device may comprise aproximal sheath, a proximal self-expanding filter assembly radiallywithin the proximal sheath, a distal sheath, and a distal self-expandingfilter assembly radially within the distal sheath.

Alternatively or additionally to any of the examples above, in anotherexample, the first self-expanding filter assembly may include aproximally facing opening.

Alternatively or additionally to any of the examples above, in anotherexample, the proximal self-expanding filter assembly may include adistally facing opening.

Alternatively or additionally to any of the examples above, in anotherexample, the distal self-expanding filter assembly may include aproximally facing opening.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device may further comprise a filter wirecoupled to a proximal end of the first self-expanding filter andextending distally therefrom.

Alternatively or additionally to any of the examples above, in anotherexample, the second protection device may further comprise a lumenconfigured to receive the filter wire of the first protection device.

Alternatively or additionally to any of the examples above, in anotherexample, the lumen may extend over less than an entire length of thesecond protection device.

Alternatively or additionally to any of the examples above, in anotherexample, the lumen may be in communication with a rapid exchange portproximally spaced from a distal end of the distal sheath.

Alternatively or additionally to any of the examples above, in anotherexample, the lumen may extend an entirety of a length of the secondprotection device.

Alternatively or additionally to any of the examples above, in anotherexample, the first protection device may further comprise an innermember radially inward of the outer sheath.

Alternatively or additionally to any of the examples above, in anotherexample, the inner member may comprise a guidewire lumen.

Alternatively or additionally to any of the examples above, in anotherexample, at least one of the first or second protection devices may beconnected to an arterial pressure monitoring device.

Alternatively or additionally to any of the examples above, in anotherexample, the distal sheath may be articulatable.

Alternatively or additionally to any of the examples above, in anotherexample, each of the first self-expanding filter, the proximalself-expanding filter, and the distal self-expanding filter may beconfigured to be individually deployed.

Alternatively or additionally to any of the examples above, in anotherexample, the embolic protection system may further comprise a firsthandle assembly coupled to the proximal portion of the first embolicprotection device and a second handle assembly coupled to the proximalportion of the second embolic protection device.

The above summary of exemplary embodiments is not intended to describeeach disclosed embodiment or every implementation of the presentdisclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention may be more completely understood in consideration of thefollowing detailed description of various embodiments in connection withthe accompanying drawings, in which:

FIGS. 1A and 1B illustrate a first embodiment for deploying threefilters to protect the cerebral vascular architecture.

FIG. 1C illustrates an alternate embodiment of the three filter systemof FIGS. 1A and 1B.

FIGS. 1D and 1E illustrate an alternate embodiment of the three filtersystem of FIG. 1C.

FIG. 2A illustrates another embodiment of a three filter system.

FIGS. 2B and 2C illustrate another alternate embodiment of the threefilter system of FIG. 2A.

FIGS. 3A-3C illustrate another alternate embodiment of a three filtersystem.

FIGS. 4A-4C illustrate another alternate embodiment of a three filtersystem.

FIG. 5 illustrates an embodiment of a two filter system deployed tofully protect the cerebral apparatus.

FIGS. 6A and 6B illustrate embodiments of deploying two filters and adeflector.

FIGS. 7A-7D illustrate embodiments where only one oversized filter isdeployed to protect the cerebral vasculature.

While the invention is amenable to various modifications and alternativeforms, specifics thereof have been shown by way of example in thedrawings and will be described in detail. It should be understood,however, that the intention is not to limit aspects of the invention tothe particular embodiments described. On the contrary, the intention isto cover all modifications, equivalents, and alternatives falling withinthe spirit and scope of the invention.

DETAILED DESCRIPTION

For the following defined terms, these definitions shall be applied,unless a different definition is given in the claims or elsewhere inthis specification.

All numeric values are herein assumed to be modified by the term“about”, whether or not explicitly indicated. The term “about” generallyrefers to a range of numbers that one of skill in the art would considerequivalent to the recited value (i.e., having the same function orresult). In many instances, the term “about” may be indicative asincluding numbers that are rounded to the nearest significant figure.

The recitation of numerical ranges by endpoints includes all numberswithin that range (e.g., 1 to 5 includes 1, 1.5, 2, 2.75, 3, 3.80, 4,and 5).

Although some suitable dimensions ranges and/or values pertaining tovarious components, features and/or specifications are disclosed, one ofskill in the art, incited by the present disclosure, would understanddesired dimensions, ranges and/or values may deviate from thoseexpressly disclosed.

As used in this specification and the appended claims, the singularforms “a”, “an”, and “the” include plural referents unless the contentclearly dictates otherwise. As used in this specification and theappended claims, the term “or” is generally employed in its senseincluding “and/or” unless the content clearly dictates otherwise.

The following detailed description should be read with reference to thedrawings in which similar elements in different drawings are numberedthe same. The detailed description and the drawings, which are notnecessarily to scale, depict illustrative embodiments and are notintended to limit the scope of the invention. The illustrativeembodiments depicted are intended only as exemplary. Selected featuresof any illustrative embodiment may be incorporated into an additionalembodiment unless clearly stated to the contrary.

The currently marketed Sentinel system made by Claret Medical andembodiments of which are described in U.S. Pat. No. 9,492,264 mentionedabove has two filters, a first which protects the right brachiocephalicartery, from which the right vertebral and right common carotid arteriestypically originate, and a second filter in the left common carotidartery. In a typical patient, the left vertebral which providesapproximately seven percent of the perfusion to the brain is leftunprotected.

One disclosed solution to protecting the left vertebral is the use of asecond device intended to be placed in the left arm, e.g. through theleft radial artery, with a filter placed in the left subclavian fromwhich the left vertebral typically originates. Embodiments of such asolution can be found in U.S. Pat. No. 9,566,144, the entirety of whichis hereby incorporated by reference herein and included as part of thisSpecification in an Appendix (labeled Appendix B) filed with this patentapplication.

While procedurally compatible, it may be preferred to achieve protectionof all cerebral vessels from one access point. Deflector concepts whichreside in the arch have been previously disclosed, and these devices canhave a single access point of either the right arm, left arm or femoralartery. While deflector concepts which reside in the arch aretechnically feasible, they may result in substantial interference withthe therapy (e.g. TAVR) or procedure, or may not be sufficientlycompatible with the breadth of sizes and configurations of aortic archesto provide complete protection of the brain.

The present application discloses several single-access multi-vesselembodiments that can provide full cerebral protection with minimal archinterference.

The disclosure generally relates to devices and methods for filteringfluids and/or deflecting debris contained within fluids, including bodyfluids such as blood. A filtering or deflecting device can be positionedin an artery before and/or during an endovascular procedure (e.g.,transcatheter aortic valve implantation (TAVI) or replacement (TAVR),transcatheter mitral valve implantation (TAMI) or replacement (TAMR),surgical aortic valve replacement (SAVR), other surgical valve repair,implantation, or replacement, cardiac ablation (e.g., ablation of thepulmonary vein to treat atrial fibrillation) using a variety of energymodalities (e.g., radio frequency (RF), energy, cryo, microwave,ultrasound), cardiac bypass surgery (e.g., open-heart, percutaneous),transthoracic graft placement around the aortic arch, valvuloplasty,etc.) to inhibit or prevent embolic material such as debris, emboli,thrombi, etc. resulting from entering the cerebral vasculature.

The devices may be used to trap and/or deflect particles in other bloodvessels within a subject, and they can also be used outside of thevasculature. The devices described herein are generally adapted to bedelivered percutaneously to a target location within a subject, but canbe delivered in any suitable way and need not be limited tominimally-invasive procedures.

FIG. 1A is a schematic view of an aortic arch 10 including a firstprotection device 30. The aortic arch 10 is upstream of the left andright coronary arteries (not explicitly shown). The aortic arch 10typically includes three great branch arteries: the brachiocephalicartery or innominate artery 12, the left common carotid artery 14, andthe left subclavian artery 16. The innominate artery 12 branches to theright carotid artery 18, then the right vertebral artery 20, andthereafter is the right subclavian artery 22. The right subclavianartery 22 supplies blood to, and may be directly accessed from (termedright radial access), the right arm. The left subclavian artery 16branches to the left vertebral artery 24, usually in the shoulder area.The left subclavian artery 16 supplies blood to, and may be directlyaccessed from (termed left radial axis), the left arm. Four of thearteries illustrated in FIG. 1A supply blood to the cerebralvasculature: (1) the left carotid artery 14 (about 40% of cerebral bloodsupply); (2) the right carotid artery 18 (about 40% of cerebral bloodsupply); (3) the right vertebral artery 20 (about 10% of cerebral bloodsupply); and (4) the left vertebral artery 24 (about 10% of cerebralblood supply).

It may be desirable to filter blood flow to all four arteries 14, 18,20, 24 supplying blood to the brain and/or deflect particulates fromentering the arteries 14, 18, 20, 24 supplying the brain. It may also bedesirable to limit the number of incision sites or cuts required todeploy the system(s). FIG. 1A illustrates a first step in deploying amulti-filter system using a right radial access incision. The firstfilter 32 may be deployed in the left subclavian artery 16 upstream ofthe left vertebral artery 24.

The protection device, or filter system, 30 comprises a proximal portion34 and a distal portion 36. The proximal portion 34 is configured to beheld and manipulated by a user such as a surgeon. The distal portion 36is configured to be positioned at a target location such as the leftsubclavian artery 16 or the left vertebral artery 24. When the distalportion 36 is configured to be positioned at the left subclavian artery16, the location may be upstream of the left vertebral artery 24 suchthat the blood is filter prior to entering the left vertebral artery 24.

The proximal portion 34 may include a handle 38, a control 40 such as aslider, an outer sheath 42, a port 44, optionally an inner membertranslation control 46 such as a knob, and optionally a hemostasis valvecontrol 48 such as a knob. The proximal portion 34 may also comprises aninner member 50 radially inward of the outer sheath 42. While notexplicitly shown, the proximal portion 34 may also comprise a filterwire 52 b radially inward of the outer sheath 42 (and sometimes radiallyoutward of the inner member 50). Some illustrative filter wires aredescribed in commonly assigned U.S. Pat. No. 9,566,144, the entirety ofwhich is hereby incorporated by reference. The filter wire 52 b may becoupled to the filter assembly 32 in the distal portion 36. The outersheath 42 may have a diameter between about 4 French (Fr) (approximately1.33 millimeters (mm)) and about 6 Fr (approximately 2 mm) (e.g., about5 Fr (approximately 1.67 mm)).

The protection device 30 may further include a guidewire 56 disposedwithin a lumen of the inner member 50. The outer sheath 42 may comprisean atraumatic distal tip. Other features of the protection device 30 andother protection devices described herein may be flexible and/oratraumatic. The outer sheath 42 may comprise a curvature, for examplebased on an intended placement location (e.g., the left subclavianartery and/or the left vertebral artery).

The slider 40 can be used to translate the outer sheath 42 and/or afilter assembly 32 (e.g., coupled to a filter wire 52 b). For example,the slider 40 may proximally retract the outer sheath 42, the slider 40may distally advance the filter assembly 32 out of the outer sheath 42,or the slider 40 may proximally retract the outer sheath 42 and distallyadvance the filter assembly 32 (e.g., simultaneously or serially), whichcan allow the filter assembly 32 to radially expand. The slider 40 mayalso be configured to have an opposite translation effect, which canallow the filter assembly 32 to be radially collapsed (e.g., due tocompression by the outer sheath 42) as the filter assembly 32 is drawninto the outer sheath 42. Other deployment systems are also possible,for example comprising gears or other features such as helical tracks(e.g., configured to compensate for any differential lengthening due toforeshortening of the filter assembly 32, configured to convertrotational motion into longitudinal motion), a mechanical element, apneumatic element, a hydraulic element, etc. for opening and/or closingthe filter assembly 32.

The port 44 is in fluid communication with the inner member 50 (e.g.,via a Y-shaped connector in the handle 38). The port 44 can be used toflush the device (e.g., with saline) before, during, and/or after use,for example to remove air. The port 44 can additionally, oralternatively, be used to monitor blood pressure at the target location,for example by connecting an arterial pressure monitoring device influid communication with a lumen of the outer sheath 42. The port 44 canbe also or alternatively be used to inject contrast agent, dye,thrombolytic agents such as tissue plasminogen activator (t-PA), etc.The slider 40 may be independent of the inner member 50 such that theinner member 50 is longitudinally movable independent of the filterassembly 32 and the outer sheath 42. The inner member translationcontrol 46 can be used to longitudinally translate the inner member 50,for example before, after, and/or during deployment of the filterassembly 32. The inner member translation control 46 may comprise aslider in the housing 38 (e.g., separate from the slider 40).

The rotatable hemostasis valve control 48 can be used to reduce orminimize fluid loss through the protection device 30 during use. Forexample, a proximal portion and/or intermediate region of the protectiondevice may be positioned in the right subclavian artery 22 and thedirection of blood flow with respect to the device 30 will be distal toproximal, so blood may be otherwise inclined to follow the pressure dropout of the device 30. The hemostasis valve control 48 is illustrated asbeing rotatable, but other arrangements are also possible (e.g.,longitudinally displaceable). The hemostasis valve control 48 may beconfigured to fix relative positions of the outer sheath 42 and thefilter assembly 32, for example as described with respect to thehemostasis valve in U.S. Pat. No. 8,876,796. The hemostasis valve 48 maycomprise, for example, an elastomeric seal and HV nut.

The distal portion 36 may include the outer sheath 42, a filter assembly32 radially inward of the outer sheath 42 in a delivery configuration(not explicitly shown), and optionally the inner member 50. The filterassembly 32 may be radially between the outer sheath 42 and the innermember 50 (e.g., radially inward of the outer sheath 42 and the innermember 50 radially inward of the filter assembly 32) in a delivery stateor shape or position.

The filter assembly 32 may include a support element or frame 31 and afilter element 33. The frame 31 may generally provide expansion supportto the filter element 33 in the expanded state. In the expanded state,the filter element 33 is configured to filter fluid (e.g., blood)flowing through the filter element 33 and to inhibit or preventparticles (e.g., embolic material) from flowing through the filterelement 33 by capturing the particles in the filter element 33.

The frame 31 is configured to engage or appose the inner walls of alumen (e.g., blood vessel) in which the frame assembly 32 is expanded.The frame 31 may comprise or be constructed of, for example, nickeltitanium (e.g., nitinol), nickel titanium niobium, chromium cobalt(e.g., MP35N, 35NLT), copper aluminum nickel, iron manganese silicon,silver cadmium, gold cadmium, copper tin, copper zinc, copper zincsilicon, copper zinc aluminum, copper zinc tin, iron platinum, manganesecopper, platinum alloys, cobalt nickel aluminum, cobalt nickel gallium,nickel iron gallium, titanium palladium, nickel manganese gallium,stainless steel, combinations thereof, and the like. The frame 31 maycomprise a wire (e.g., having a round (e.g., circular, elliptical) orpolygonal (e.g., square, rectangular) cross-section). For example, insome embodiments, the frame 31 comprises a straight piece of nitinolwire shape set into a circular or oblong hoop or hoop with one or twostraight legs running longitudinally along or at an angle to alongitudinal axis of the frame assembly 32. At least one of the straightlegs may be coupled to a filter wire 52 a or a strut 52 a. The straightlegs may be on a long side of the filter assembly 32 and/or on a shortside of the filter assembly 32. The frame 31 may form a shape of anopening 35 of the filter assembly 32. The opening 35 may be circular,elliptical, or any shape that can appropriately appose sidewalls of avessel such as the left subclavian artery or the left vertebral artery.The filter assembly 32 may have a generally proximally-facing opening35. In other embodiments, the opening 35 may be distally facing. Theorientation of the opening 35 may vary depending on where the accessincision is located.

The frame 31 may include a radiopaque marker such as a small coilwrapped around or coupled to the hoop to aid in visualization underfluoroscopy. In some embodiments, the frame may not comprise a shapeother than a hoop, for example a spiral. In some embodiments, the filterassembly 32 may not include or be substantially free of a frame.

In some embodiments, the frame 31 and the filter element 33 form anoblique truncated cone having a non-uniform or unequal length around andalong the length of the filter assembly 32. In such a configuration,along the lines of a windsock, the filter assembly 32 has a largeropening 35 (upstream) diameter and a reduced ending (downstream)diameter.

The filter element 33 may include pores configured to allow blood toflow through the filter element 33, but that are small enough to inhibitprevent particles such as embolic material from passing through thefilter element 33. The filter element 33 may comprise a filter membranesuch as a polymer (e.g., polyurethane, polytetrafluoroethylene (PTFE))film mounted to the frame 32. The filter element may have a thicknessbetween about 0.0001 inches and about 0.03 inches (e.g., no more thanabout 0.0001 inches, about 0.001 inches, about 0.005 inches, about 0.01inches, about 0.015 inches, about 0.02 inches, about 0.025 inches, about0.03 inches, ranges between such values, etc.).

The film may comprise a plurality of pores or holes or aperturesextending through the film. The film may be formed by weaving orbraiding filaments or membranes and the pores may be spaces between thefilaments or membranes. The filaments or membranes may comprise the samematerial or may include other materials (e.g., polymers, non-polymermaterials such as metal, alloys such as nitinol, stainless steel, etc.).The pores of the filter element 33 are configured to allow fluid (e.g.,blood) to pass through the filter element 33 and to resist the passageof embolic material that is carried by the fluid. The pores can becircular, elliptical, square, triangular, or other geometric shapes.Certain shapes such as an equilateral triangular, squares, and slots mayprovide geometric advantage, for example restricting a part larger thanan inscribed circle but providing an area for fluid flow nearly twice aslarge, making the shape more efficient in filtration verses fluidvolume. The pores may be laser drilled into or through the filterelement 33, although other methods are also possible (e.g., piercingwith microneedles, loose braiding or weaving). The pores may have alateral dimension (e.g., diameter) between about 10 micron (μm) andabout 1 mm (e.g., no more than about 10 μm, about 50 μm, about 100 μm,about 150 μm, about 200 μm, about 250 μm, about 300 μm, about 400 μm,about 500 μm, about 750 μm, about 1 mm, ranges between such values,etc.). Other pore sizes are also possible, for example depending on thedesired minimum size of material to be captured.

The material of the filter element 33 may comprise a smooth and/ortextured surface that is folded or contracted into the delivery state bytension or compression into a lumen. A reinforcement fabric may be addedto or embedded in the filter element 33 to accommodate stresses placedon the filter element 33 during compression. A reinforcement fabric mayreduce the stretching that may occur during deployment and/or retractionof the filter assembly 32. The embedded fabric may promote a folding ofthe filter to facilitate capture of embolic debris and enable recaptureof an elastomeric membrane. The reinforcement material could comprise,for example, a polymer and/or metal weave to add localized strength. Thereinforcement material could be imbedded into the filter element 33 toreduce thickness. For example, imbedded reinforcement material couldcomprise a polyester weave mounted to a portion of the filter element 33near the longitudinal elements of the frame 31 where tensile forces actupon the frame 31 and filter element 33 during deployment and retractionof the filter assembly 32 from the outer sheath 42.

In some cases, the filter assembly 32 may include a self-expandingfilter assembly (e.g., comprising a superelastic material withstress-induced martensite due to confinement in the outer sheath 42).The filter assembly 32 may comprise a shape-memory material configuredto self-expand upon a temperature change (e.g., heating to bodytemperature). The filter assembly 32 may comprise a shape-memory orsuperelastic frame (e.g., comprising a distal end hoop comprisingnitinol) and a microporous material (e.g., comprising a polymerincluding laser-drilled holes) coupled to the frame, for example similarto the filter assemblies described in U.S. Pat. No. 8,876,796.

The filter assembly 32 may be coupled (e.g., crimped, welded, soldered,etc.) to a distal end of a deployment wire or filter wire 52 b via astrut or wire 52 a. When both or all of the filter wire 52 a and thestrut 52 a are provided, the filter wire 52 b and the strut 52 a may becoupled within the outer sheath 42 proximal to the filter assembly 30using a crimp mechanism. In other embodiments, the filter wire 52 b andthe strut 52 a may be a single unitary structure. The filter wire 52 band/or strut 52 a can comprise a rectangular ribbon, a round (e.g.,circular, elliptical) filament, a portion of a hypotube, a braidedstructure (e.g., as described herein), combinations thereof, and thelike. The filter wire 52 b can be coupled to the handle 38 and/or theslider 40 to provide differential longitudinal movement versus the outersheath 42, as shown by the arrows 54, which can sheathe and unsheathethe filter assembly 32 from the outer sheath 42.

The filter assembly 32 in an expanded, unconstrained state has a maximumdiameter or effective diameter (e.g., if the mouth is in the shape of anellipse) d. The diameter d can be between about 1 mm and about 15 mm(e.g., at least about 1 mm, about 2 mm, about 3 mm, about 4 mm, about 5mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, rangesbetween such values, etc.). In some embodiments (e.g., when the filterassembly is configured to be positioned in the left subclavian artery),the diameter d is between about 7 mm and about 12 mm (e.g., about 7 mm,about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, rangesbetween such values, etc.). In some embodiments (e.g., when the filterassembly is configured to be positioned in the left vertebral artery),the diameter d is between about 2 mm and about 4.5 mm (e.g., about 2 mm,about 2.5 mm, about 3 mm, about 3.5 mm, about 4 mm, about 4.5 mm, rangesbetween such values, etc.). Other diameters d or other types of lateraldimensions are also possible. Different diameters d can allow treatmentof a selection of subjects having different vessel sizes.

The filter assembly 32 has a maximum length 1. The length 1 can bebetween about 7 mm and about 50 mm (e.g., at least about 7 mm, about 8mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm,about 14 mm, about 15 mm, about 16 mm, about 17 mm, about 18 mm, about19 mm, about 20 mm, about 21 mm, about 22 mm, about 23 mm, about 24 mm,about 25 mm, about 30 mm, about 35 mm, about 40 mm, about 45 mm, about50 mm, ranges between such values, etc.). Other lengths 1 are alsopossible, for example based on the diameter or effective diameter d. Forexample, the length 1 of the filter assembly 32 may increase as thediameter d increases, and the length 1 of the filter assembly 32 maydecrease as the diameter d decreases. A distance from an apex of themouth of the filter assembly 32 to an elbow in the frame may be about 35mm. Different lengths 1 can allow treatment of a selection of subjectshaving different vessel sizes.

The inner member 50 may be optional, but can provide additional usesand/or advantages in combination with the filter assembly 32. Forexample, the inner member 50 may comprise a guidewire lumen (notexplicitly shown), allowing the device 30 to be tracked over a guidewire56 without contacting the filter assembly 32. For another example, alumen of the inner member 50 may be fluidly coupled to the flush port44, which can allow flushing of fluid through the inner member 50, forexample to remove air. For yet another example, a lumen of the innermember 50 may be connected to an arterial pressure monitoring device,allowing measurement of pressure proximate to the location of the filterassembly 32.

The distal portion 36 may include fluoroscopic markers one or more 58 a,58 b to aid a user in positioning the device 30, deploying the filterassembly 32, utilizing the inner member 50, etc. A fluoroscopic marker58 b may be positioned is proximate to a distal end of the outer sheath42. Another fluoroscopic marker (not explicitly shown) may be positionedproximate to a proximal end of the filter assembly 32. In some cases,another fluoroscopic marker 58 b maybe proximate to a distal end of thefilter assembly 32. Another fluoroscopic marker (not explicitly shown)may be proximate to a distal end of the inner member 50. Thefluoroscopic markers may comprise a radiopaque material (e.g., iridium,platinum, tantalum, gold, palladium, tungsten, tin, silver, titanium,nickel, zirconium, rhenium, bismuth, molybdenum, combinations thereof,and the like). More or fewer fluoroscopic markers are also possible.

The protection device 30 is illustrated as comprising a guidewire 56therethrough, although the guidewire 56 may be characterized as beingseparate from the protection device 30, for example independently sold,packaged, and/or directed. The guidewire 56 may extend through a lumenof the outer sheath 42 or the inner member 50. The lumen of the outersheath 42 or the inner member 50 (if so provided) may be configured toreceive a guidewire 56 having a diameter between about 0.014 inches(0.356 mm) and about 0.025 inches (0.635 mm). The guidewire 56 mayextend through a lumen of the filter assembly 32. For example, theprotection device 30 may be tracked over the guidewire 56 to positionthe protection device 30 at a desired location.

The filter assembly 32 may be positioned, for example, in the leftsubclavian artery 16, to protect the cerebral vasculature (e.g., theleft vertebral artery 24) from embolic debris during an endovascularprocedure such as TAVI. While the procedure described positioning thefirst filter assembly 32 in the left subclavian artery, the method isnot limited to positioning the first filter assembly 32 within the leftsubclavian artery, the first filter assembly 32 may be positioned withinother arteriers (or other lumens), as desired. The filter assembly 32may be positioned in the left subclavian artery 16 upstream of the leftvertebral artery 24. The user may choose a protection device 30comprising a proximal-facing filter assembly 32 having a diameterappropriate for the artery (or other lumen) in which it is to bedeployed, for example, but not limited to, between about 7 mm and about12 mm for the left subclavian artery 16. The protection device 30 may bepackaged in a sterile coiled packaging. The protection device 30 maycomprise an outer sheath 42 having a diameter of about 5 Fr(approximately 1.67 mm). The outer sheath 42 may include a curvature,for example complementing the size and orientation of the filterassembly 32. The outer sheath 42 may be steerable (e.g., a pullwire-controlled sheath).

Lumens of the protection device 30, for example a lumen of the outersheath 42 and a lumen of the inner member 50, may be flushed (e.g.,using saline) once or several times before, during, and/or after theprocedure. The filter assembly 32 of the protection device 30 may beflushed and/or submerged (e.g., in a bowl of saline). Flushing and/orsubmerging of the filter assembly 32 may be with the filter assembly 32in the outer sheath 42 (e.g., in the compressed state) and/or with thefilter assembly 32 out of the outer sheath 42 (e.g., in the deployedstate). If the filter assembly 32 is flushed and/or submerged in thedeployed state, the filter assembly 32 may be compressed into the outersheath 42 before use.

An artery in the right arm is accessed, for example using a 5 Frintroducer. The guidewire 56 (e.g., having a diameter between about0.014 inches and about 0.25 inches) is steered, into or towards theright subclavian artery 22, then into the innominate artery 12, theninto the aortic arch 10, and finally into the left subclavian artery 16.In some cases, a distal end of the guidewire 56 may be curved (e.g., apigtail curve) to facilitate navigation from the right subclavian artery22 to the left subclavian artery 16. A proximal end of the guidewire maybe inserted into a distal end of the protection device 30, for exampleinto a distal end of an inner member 50. During navigation through thevasculature, the filter assembly 32 may be disposed within a lumen ofthe outer sheath and held in a collapsed position therein until thefilter assembly 32 advanced distally from the outer sheath 42 and/or theouter sheath 42 is proximally retracted relative to the filter assembly32. The protection device 30 may be tracked over the guidewire until thedistal end of the protection device 30 extends beyond a distal end ofthe introducer. In some implementations, the guidewire and theprotection device 30 may be tracked together, with the guidewire leadingthe device 30 (e.g., advance the guidewire a distance, then advance thedevice 30 over the guidewire approximately the same distance). In somecases, where the guidewire and the inner member 50 may both be floppy orlack rigidity, they may be introduced inside the outer sheath 42 andthen advanced ahead of the device 30 in the vasculature. The guidewiremay be advanced at least about 6 centimeters (cm) distal to the distalend of the protection device 30.

The protection device 30 may be tracked or distally advanced over theguidewire until the proximal end of the protection device 30 (e.g., theopening 35) is at a desired location such as proximate to the leftsubclavian artery ostium 17, just above the aortic arch 10. Tracking ofthe protection device 30 may be performed under fluoroscopy, for exampleusing radiopaque markers (e.g., at a distal end of the outer sheath 42and/or the inner member 50) and/or radiopaque fluid or contrast media.Radiopaque fluid may be provided through the inner member 50 and/or theouter sheath 42. The protection device 30 may be positioned so that thefilter assembly 32 is upstream of the left vertebral artery 24 orproximate to the ostium 17 so that the filter assembly 32 can inhibit orprevent embolic material from entering the cerebral vasculature throughthe left vertebral artery 24. Using terminology of the procedure ratherthan blood flow, the protection device 30 is preferably positioned sothat the filter assembly 32 is proximal to the point in the leftsubclavian artery 16 where the left vertebral artery 24 branches off.However, it is contemplated that positioning may be based on availableanatomy.

Once the protection device 30 is in position, the filter assembly 32 maybe deployed from the outer sheath 42. For example, the outer sheath 42may be proximally retracted and/or the filter assembly 32 may bedistally advanced. Radiopaque markers, for example on the filterassembly 32 can help determine when the filter assembly 32 achieves adeployed state. Differential longitudinal movement of the filterassembly 32 and the outer sheath 42 can cease upon full or appropriatedeployment of the filter assembly 32. Apposition of the filter assembly32 with sidewalls of the left subclavian artery 16 can be verified, forexample using radiopaque fluid or contrast media. Radiopaque fluid maybe provided through the inner member 50. If the radiopaque fluid is ableto flow between the frame of the filter assembly 32 and the sidewalls ofthe left subclavian artery 16, then the filter assembly 32 may beimproperly positioned (e.g., indicative of inadequate deployment,inadequate sizing, calcium, etc.). The filter assembly 32 may beretracted back into the outer sheath 42 and redeployed, or a differentprotection device may be used.

After positioning of the protection device 30, the outer sheath 42 andthe inner member 50 may be withdrawn while the filter wire 52 b and/orstrut 52 a are left in place. It is contemplated that the filter wire 52b and/or strut 52 a may function as a guidewire to direct the outersheath 42 back to the filter assembly 32 when removal of the filterassembly 32 is desired. Alternatively, or additionally, the guidewire 56may be left in place during the endovascular procedure (e.g., TAVI,TAVR, TAMI, TAMR, SAVR, other surgical valve repair, implantation, orreplacement, cardiac ablation, cardiac bypass surgery, etc.). In someembodiments, the inner member 50 may be retracted to a position suitablefor monitoring or sensing blood pressure. For example, a blood pressuremonitoring device can be connected in fluid communication to the innermember 50 (e.g., using a luer fitting). In embodiments in which theprotection device lacks an inner member, blood pressure may be monitoredor sensed by connecting a blood pressure monitoring device to the outersheath 42.

The protection devices described herein may be used alone or incombination with other protection devices. For example, a secondprotection device as described herein may be advanced via the rightsubclavian artery and positioned in both the innominate artery 12 andthe left common carotid artery 14, providing protection to the rightcarotid artery, the right vertebral artery, and the left carotid artery14. For another example, an aortic arch filter or deflector such as theEmbrella Embolic Deflector System, the TriGuard embolic protectionsystem, or the like may be placed across the great branch artery ostiaand/or apposing sidewalls of the aortic arch upstream of at least one ofthe great branch artery ostia. For another example, the filter systemsand methods described in U.S. Pat. No. 8,876,796 can be used incombination with the protection devices described herein to furtherprotect the cerebral vasculature during an endovascular procedure.

For example, after the first filter assembly 32 has been positioned, asecond protection device, or filter system, 60 may be deployed in theinnominate artery 12 and the left common carotid artery 14, as shown inFIG. 1B. FIG. 1B illustrates an example distal portion of a secondprotection device 60 having two filter assemblies 62, 64 in a deployedstate. Illustrative protection devices including two filter assembliesare described in commonly assigned U.S. Pat. No. 9,492,264, the entiretyof which is hereby incorporated by reference.

The second protection device 60 may include a distal end region 66including at least the filter assembles 62, 64 and a proximal end region(not explicitly shown) coupled to a handle (not explicitly shown)configured to remain outside the body. In some cases, the handle of thesecond protection device 60 may be similar in form and function to thehandle 38 described herein. The distal end region 66 may include aproximal sheath 68, a proximal shaft 70 coupled to an expandableproximal filter assembly 64, a distal shaft 72 coupled to a distalarticulatable sheath 74, a distal filter 62, and guiding member 76.

The proximal shaft 70 is co-axial with proximal sheath 68, and aproximal region 78 of proximal filter assembly 64 is secured to proximalshaft 70. In its collapsed configuration (not explicitly shown), theproximal filter assembly 64 may be disposed within proximal sheath 68and is disposed distally relative to proximal shaft 70. The proximalsheath 68 may be axially (distally and proximally) movable relative toproximal shaft 70 and the proximal filter assembly 64. The system 60 mayalso include a distal sheath 74 secured to a distal region of distalshaft. The distal shaft 72 may be co-axial with the proximal shaft 70and the proximal sheath 68. The distal sheath 74 and distal shaft 72 maybe secured to one another axially movable relative to proximal sheath68, the proximal shaft 70 and the proximal filter assembly 64. Thesystem 60 may also include a distal filter assembly 62 carried by theguiding member 76. While not explicitly shown, the distal filterassembly 62 may be maintained in a collapsed configuration within thedistal sheath 74. The guiding member 76 may be coaxial with distalsheath 74 and distal shaft 72 as well as proximal sheath 68 and proximalshaft 70. The guiding member 76 may be axially movable relative todistal sheath 74 and distal shaft 72 as well as proximal sheath 68 andproximal shaft 70. The proximal sheath 68, the distal sheath 74, and theguiding member 76 may each be adapted to be independently moved axiallyrelative to one other. That is, the proximal sheath 68, the distalsheath 74, and the guiding member 76 are adapted for independent axialtranslation relative to each of the other two components. It iscontemplated that the handle may include control elements (such as, butnot limited to, slides, switches, buttons, dials, etc.) configured toindividually actuate the proximal sheath 68, the distal sheath 74, andthe guiding member 76.

The proximal filter assembly 64 may include a support element or frame65 and filter element 67. Similarly, the distal filter assembly 62includes support element 61 and filter element 63. The frames 61, 65 maybe similar in form and function to the frame 31 described herein.Similarly, the filter elements 63, 67 may be similar in form andfunction to the filter element 33 described herein. The support elements61, 65 generally provide expansion support to the filter elements 63, 67in their respective expanded configurations, while the filter elements63, 67 are adapted to filter fluid, such as blood, and trap particlesflowing therethrough. The expansion supports 61, 65 are adapted toengage the wall of the lumen in which they are expanded. The filterelements 63, 67 have pores therein that are sized to allow the blood toflow therethrough, but are small enough to prevent unwanted foreignparticles from passing therethrough. The foreign particles are thereforetrapped by and within the filter elements 63, 67.

As shown in FIG. 1B, the proximal filter 64 has a generallydistally-facing opening 80, and the distal filter 62 has a generallyproximally-facing opening 82 relative to the device 60. The filterassemblies 62, 64 can be thought of as facing opposite directions. Asdescribed in more detail below, the distal sheath 74 may be adapted tobe steered, or bent, relative to the proximal sheath 68 and the proximalfilter 64. As the distal sheath 74 is steered, the relative directionsin which the openings face will be adjusted. Regardless of the degree towhich the distal sheath 74 is steered, the filter assemblies 62, 64 arestill considered to having openings facing opposite directions. Forexample, the distal sheath 74 could be steered to have an approximately720 degree bend, in which case the filter assemblies 62, 64 would haveopenings 82, 80 facing in substantially the same direction, as shown inFIG. 1B. The directions of the filter openings 80, 82 are thereforedescribed if the system were to assume a substantially straightenedconfiguration (not explicitly shown). The proximal filter element 67 maytaper down in the proximal direction from support element 65, while thedistal filter element 63 may taper down in the distal direction fromsupport element 61. A fluid, such as blood, flows through the openingand passes through the pores in the filter elements 63, 67, while thefilter elements 63, 67 are adapted to trap foreign particles therein andprevent their passage to a location downstream of the filter assemblies.

The filters 62, 64 may be secured to separate system components. Forexample, the proximal filter assembly 64 is secured to the proximalshaft 70, while the distal filter assembly 62 is secured to guidingmember 76. In FIG. 1B, the filters 62, 64 are secured to independentlyactuatable components. This may allow the filters 62, 64 to beindependently positioned and controlled. Additionally, the filters 62,64 may be collapsed within two different tubular members in theircollapsed configurations. For example, the proximal filter assembly 64is collapsed within proximal sheath 68, while the distal filter assembly62 is collapsed within distal sheath 74. In the system's deliveryconfiguration, the filter assemblies 62, 64 are axially-spaced from oneanother. For example, in FIG. 1B, the distal filter assembly 62 isdistally-spaced relative to proximal filter assembly 64. However, in analternative embodiment, the filter assemblies 62, 64 may be positionedsuch that a first filter is located within a second filter.

In some embodiments, the distal sheath 74 and the proximal sheath 68have substantially the same outer diameter. When the filter assemblies62, 64 are collapsed within the sheaths, the sheath portion of thesystem 60 therefore has a substantially constant outer diameter, whichcan ease the delivery of the system 60 through the patient's body andincrease the safety of the delivery. The distal and proximal sheaths 74and 68 may have substantially the same outer diameter, both of whichhave larger outer diameters than the proximal shaft 70. The proximalshaft 70 may have a larger outer diameter than the distal shaft 72,wherein the distal shaft 72 is disposed within the proximal shaft 70.The guiding member 76 may have a smaller diameter than the distal shaft72. In some embodiments the proximal and distal sheaths 68, 74 have anouter diameter between 3 French (F) and 70 F. In certain embodiments,the outer diameter is between 4 F and 8 F. In still other embodiments,the outer diameter is between 4 F and 6 F. In some embodiments, thesheaths 68, 74 have different outer diameters. For example, the proximalsheath 68 can have a size of 6 F, while the distal sheath 74 has a sizeof 5 F. In an alternate embodiment the proximal sheath 68 is 5 F and thedistal sheath 74 is 4 F. These are just examples and are not intended tolimit the sheaths 68, 74 to a particular size. A distal sheath 74 with asmaller outer diameter than the proximal sheath 68 reduces the deliveryprofile of the system 60 and can ease delivery. In some methods of use,the filter system 60 is advanced into the subject through an incisionmade in the subject's right radial artery, or alternatively the rightbrachial artery. In a variety of medical procedures a medical instrumentis advanced through a subject's femoral artery, which is larger than theright radial artery. A delivery catheter used in femoral artery accessprocedures has a larger outer diameter than would be allowed in a filtersystem advanced through a radial artery. Additionally, in some uses thefilter system is advanced from the right radial artery into the aortavia the brachiocephalic trunk. The radial artery has the smallestdiameter of the vessels through which the system is advanced. The radialartery therefore limits the size of the system that can be advanced intothe subject when the radial artery is the access point. The outerdiameters of the systems described herein, when advanced into thesubject via a radial artery, are therefore smaller than the outerdiameters of the guiding catheters (or sheaths) typically used whenaccess is gained via a femoral artery.

The system 60 may be delivered to the left carotid artery 14 and theinnominate artery 12 in a delivery configuration. The system's deliveryconfiguration generally refers to the configuration when both filterassemblies 62, 64 are in collapsed configurations within the system. Thedistal articulating sheath 74 may be independently movable with 3degrees of freedom relative to the proximal sheath 68 and proximalfilter 64. In some embodiments, the proximal sheath 68 and the distalsheath 74 may be releasably coupled together. For example, the proximalsheath 68 can be coupled to the distal sheath 74 using an interferencefit, a friction fit, a spline fitting, end to end butt fit or any othertype of suitable coupling between the two sheaths 68, 74. When coupledtogether, the components move as a unit. For example, the proximalsheath 68, the proximal shaft 70, the proximal filter 64, the distalshaft 72, and the distal filter 62 will rotate and translate axially (inthe proximal or distal direction) as a unit. When proximal sheath 68 isretracted to allow proximal filter 64 to expand, the distal sheath 74can be independently rotated, steered, or translated axially (either inthe proximal direction or distal direction). The distal sheath 74therefore has 3 independent degrees of freedom: axial translation,rotation, and steering. The adaptation to have 3 independent degrees offreedom is advantageous when positioning the distal sheath 74 in atarget location, details of which are described below.

The system 60 is advanced into the subject's right radial artery throughan incision in the right arm, or alternately through the right brachialartery. For example, the system 60 may be advanced through the sameincision as the first system 30. The system is advanced through theright subclavian artery 22 and into the brachiocephalic or innominateartery 12, and a portion of the system is positioned within aortic arch10. The proximal sheath 68 is retracted proximally to allow proximalfilter support element 65 to expand to an expanded configuration againstthe wall of the innominate artery 12, as is shown in FIG. 1B. Theproximal filter element 67 is secured either directly or indirectly tosupport element 65 and is therefore reconfigured to the configurationshown in FIG. 1B. The position of distal sheath 74 can be substantiallymaintained while proximal sheath 68 is retracted proximally. Onceexpanded, the proximal filter assembly 64 filters blood travelingthrough the innominate artery 12, and therefore filters blood travelinginto the right common carotid artery 18 and the right vertebral artery20. The expanded proximal filter assembly 64 is therefore in position toprevent foreign particles from traveling into the right common carotidartery 18 and the right vertebral artery 20 and into the cerebralvasculature.

The distal sheath 74 is then steered, or bent, and the distal end 84 ofthe distal sheath 74 is advanced into the left common carotid artery 14.The guiding member 76 is thereafter advanced distally relative to distalsheath 74, allowing the distal support element 61 to expand from acollapsed configuration to a deployed configuration against the wall ofthe left common carotid artery 14, as shown in FIG. 1B. The distalfilter element 63 is also reconfigured into the configuration shown inFIG. 1B. Once expanded, the distal filter assembly 62 filters bloodtraveling through the left common carotid artery 14. In someembodiments, the distal filter assembly 62 may be deployed prior to thedeployment of the proximal filter assembly 64. The distal filterassembly 62 is therefore in position to trap foreign particles andprevent them from traveling into the cerebral vasculature. As can beseen in FIG. 1B, together the first protection system 30 and the secondprotection system 60 collectively trap foreign particles and preventthem from traveling into the four arteries 14, 18, 20, 24 that carryoxygenated blood to the brain.

The filter system(s) 30, 60 can thereafter be removed from the subject(or at any point in the procedure). In an exemplary embodiment, distalfilter assembly 62 is first retrieved back within distal sheath 74 tothe collapsed configuration. To do this, the guiding member 76 isretracted proximally relative to the distal sheath 74. This relativeaxial movement causes the distal sheath 74 to engage a strut or wire 86and begin to move strut 86 towards guiding member 76. The supportelement 61, which is coupled to the strut 86, begins to collapse uponthe collapse of the strut 86. The filter element 63 therefore begins tocollapse as well. Continued relative axial movement between the guidingmember 76 and the distal sheath 74 continues to collapse the strut 86,the support element 61, and the filter element 63 until the distalfilter assembly 62 is retrieved and re-collapsed back within distalsheath 74 (not explicitly shown). Any foreign particles trapped withinthe distal filter element 63 are contained therein as the distal filterassembly 62 is re-sheathed. The distal sheath 74 is then steered into aconfiguration where the distal sheath 74 is generally parallel with thedistal shaft 72. Said differently, the distal sheath 74 is steered suchthat it has generally linear orientation. The proximal sheath 70 is thenadvanced distally relative to proximal filter assembly 64. This causesproximal filter assembly 64 to collapse around distal shaft 72, trappingany particles within the collapsed proximal filter 67. The proximalsheath 68 continues to be moved distally towards the distal sheath 74until the proximal sheath 68 is coupled with or nearly coupled with thedistal sheath 74. The entire system 60 can then be removed from thesubject.

Once the second filter system 60 has been removed from the body, theouter sheath 42 of the first filter system 30 can be advanced (e.g.,over a guidewire 56 or the filter wire 52 b) such that the filterassembly 32 may be retracted back into the outer sheath 42 (e.g., bydistally advancing the outer sheath 42 and/or by proximally retractingthe filter assembly 32). The action to re-sheathe the filter assembly 32may by opposite to the action to unsheathe the filter assembly 32 (e.g.,retraction of a slider and advancement of the slider, respectively) ormay be a completely different action. The inner member 50 may bedistally advanced before, during, or after re-sheathing of the filterassembly 32. Radiopaque markers, for example on the filter assembly 32can help determine when the filter assembly 32 achieves a compressedstate. Differential longitudinal movement of the filter assembly 32 andthe outer sheath 42 can cease upon full or appropriate capture of thefilter assembly 32. Radiopaque fluid may be provided through the innermember 50. Embolic material trapped in the filter assembly 32 may alsobe captured by the re-sheathing process. Once the protection device 30is in a compressed state, the protection device 30 may be proximallyretracted out of the right subclavian artery 22.

In any of the embodiments mentioned herein, the filter or filterassemblies 32, 62, 64 may alternatively be detached from the deliverycatheter, and the delivery catheter removed leaving the filter 32, 62,64 behind. The filter or filter assemblies 32, 62, 64 can be left inplace permanently, or retrieved by snaring it with a retrieval catheterfollowing a post procedure treatment period of time. Alternatively, thefilter assemblies 32, 62, 64 may remain attached to the catheter, andthe catheter may be left in place post procedure for the treatmentperiod of time. That treatment period may be at least one day, one week,three weeks, five weeks or more, depending upon the clinicalcircumstances. Patients with an indwelling filter or filter assembliesmay be administered any of a variety of thrombolytic or anticoagulanttherapies, including tissue plasminogen activator, streptokinase,coumadin, heparin and others known in the art.

FIG. 1C illustrates an alternative embodiment for the systems of FIGS.1A and 1B. In FIG. 1B, the filter wire 52 b remains within the body(e.g., within the vasculature) but remains outside of the second filtersystem 60. In the embodiment of FIG. 1C, the first filter system 30 maybe deployed as discussed above. The second filter system 60 may then beadvanced over the filter wire 52 b of the first filter system 30 via aport 90 in the distal sheath 74. The filter wire 52 b is containedwithin a lumen of the second filter system 60 for a length less than anentirety of the length of the second first system 60 rather than runningalong and outside of the second filter system 60. The second filtersystem 60 may then be deployed as discussed above.

FIGS. 1D and 1E illustrate another alternative embodiment for thesystems of FIGS. 1A and 1B. In the embodiment of FIG. 1D, the distalshaft 72 may include a rapid exchange port 92 which is illustrated inmore detail in FIG. 1E. The rapid exchange port 92 may allow the filterwire 52 b to distally exit second filter system proximal to the proximalfilter assembly 64. A second port (not explicitly shown) may be formedin the second filter system 60 at a location distal to the rapidexchange port 92 to allow the filter wire 52 b to enter the secondfilter system 60. In some cases, the filter wire 52 b may enter then thesecond filter system through a port 90 in the distal sheath 74, althoughthis is not required. It is contemplated that the filter wire 52 b mayenter through a port formed in any of the components of the secondfilter system 60 or through a distal opening of any of the components ofthe second filter system 60, as desired. It is further contemplate thatthe rapid exchange port 92 may be port formed in any of the componentsof the second filter system 60, as desired. For example, as the secondfilter system 60 is advanced into the vasculature, the proximal end ofthe filter wire 52 b may inserted into the port 90 (or other suitableopening). The rapid exchange port 92 may include features that directthe proximal end of the filter wire 52 b out of the rapid exchange port92 as the second filter system 60 is distally advanced over the filterwire 52 b. As can be seen in FIG. 1E, the filter wire 52 b may deflectedinto and out of the rapid exchange port 92. It should be understood thatthe distal shaft 72 may include other components within the lumen 73thereof; however, for clarity, these components are not illustrated.

FIG. 2A illustrates another illustrative protection device, or filtersystem, 100 in which three filters are delivered with a single deliverydevice. The filter system 100 may be similar to the second filter system60 described above. The filter system 100 may include a distal endregion 102 including at least a first filter assembly 104, a secondfilter assembly 106, and a third filter assembly 108 and a proximal endregion (not explicitly shown) coupled to a handle (not explicitly shown)configured to remain outside the body. The first filter assembly 104,second filter assembly 106, and third filter assembly 108 may eachinclude a support member or frame 114, 116, 118 and a filter element120, 122, 124. The support members 114, 116, 118 may be similar in formand function to the support member 31 described herein. The filterelements 120, 122, 124 may be similar in form and function to the filterelement 33 described herein. In some cases, the handle of the filtersystem 100 may be similar in form and function to the handle 38described herein. The distal end region 102 may include a proximalsheath 110, a proximal shaft (not explicitly shown) coupled to anexpandable proximal, or third, filter assembly 108, a distal shaft 132(see, FIG. 2B) coupled to a distal articulatable sheath 112, anintermediate, or second, filter assembly 106, a distal, or first filterassembly 104, and guiding member (not explicitly shown). As can be seen,the filter system 100 may be structurally similar to the second filtersystem 100 described herein and may be similarly arranged. However, inthe filter system 100 illustrated in FIG. 2A, both the first filterassembly 104 and the second filter assembly 106 may be loaded into thedistal sheath 112 for delivery. The first and second filter assemblies104, 106 may be coupled together via a wire or tether 126. In somecases, the tether 126 may be made having a predetermined shape to betterassist the tether 126 in seating and spanning the distance from theostium of the left subclavian artery 16 to the left common carotidartery 14.

The system 100 is advanced into the subject's right radial arterythrough an incision in the right arm, or alternatively through the rightbrachial artery. While not explicitly shown, the system 100 may beadvanced over or in conjunction with one or more guidewires. The systemis advanced through the right subclavian artery 22 and into theinnominate artery 12, and a portion of the system is positioned withinaortic arch 10. The proximal sheath 110 is retracted proximally to allowproximal filter support element 118 to expand to an expandedconfiguration against the wall of the innominate artery 12, as is shownin FIG. 2A. The proximal filter element 124 is secured either directlyor indirectly to support element 118 and is therefore reconfigured tothe configuration shown in FIG. 2A. The position of distal sheath 112can be substantially maintained while proximal sheath is retractedproximally. Once expanded, the proximal filter assembly 108 filtersblood traveling through the innominate artery 12, and therefore filtersblood traveling into the right common carotid artery 18 and the rightvertebral artery 20. The expanded proximal filter assembly 108 istherefore in position to prevent foreign particles from traveling intothe right common carotid artery 18 and the right vertebral artery 20 andinto the cerebral vasculature.

The distal sheath 112 is then steered, or bent, and the distal end ofthe distal sheath 112 is advanced into the left subclavian artery 16.The guiding member (not explicitly shown) is thereafter advanceddistally relative to distal sheath 112, allowing the distal supportelement 114 to expand from a collapsed configuration to a deployedconfiguration against the wall of the left subclavian artery 16, asshown in FIG. 2A. Alternatively, or additionally, the distal sheath 112may be proximally retracted to deploy the distal filter assembly 104.The distal filter element 120 is also reconfigured into theconfiguration shown in FIG. 2A. Once expanded, the distal filterassembly 104 filters blood traveling through the left subclavian artery16. The expanded distal filter assembly 104 is therefore in positionedto prevent foreign particles from traveling into the left subclavianartery 16 and the left vertebral artery 24 and into the cerebralvasculature

Once the distal filter assembly 104 has been positioned in the leftsubclavian artery, the tether 126 may be distally advanced to provideadditional length or “slack” to allow the distal sheath 112 to berepositioned. The distal sheath 112 may be manipulated to then cannulatethe left common carotid artery 14. The guiding member (not explicitlyshown) is thereafter advanced distally relative to distal sheath 112,allowing the intermediate support element 116 to expand from a collapsedconfiguration to a deployed configuration against the wall of the leftcommon carotid artery 14, as shown in FIG. 2A. The intermediate filterelement 122 is also reconfigured into the configuration shown in FIG.2A. Once expanded, the intermediate filter assembly 106 filters bloodtraveling through the left common carotid artery 14. In someembodiments, the distal filter assembly 104 and the intermediate filterassembly 106 may be deployed prior to the deployment of the proximalfilter assembly 108. The intermediate filter assembly 106 is thereforein position to trap foreign particles and prevent them from travelinginto the cerebral vasculature. As can be seen in FIG. 2A, the protectionsystem 100 traps foreign particles and prevent them from traveling intothe four arteries 14, 18, 20, 24 that carry oxygenated blood to thebrain. It is contemplated that when the procedure is completed, theinsertion steps may be performed in reverse to remove the system 100.

FIGS. 2B and 2C illustrate an alternative embodiment of the illustrativeprotection device, or filter system, 100 of FIG. 2A in which threefilters are delivered with a single delivery device. In the embodimentof FIGS. 2B and 2C, the first and second filter assemblies 104, 106 eachinclude their own filter wire 128, 130. For example, the first andsecond filter assemblies 104, 106 may be free from the tether 126illustrated in FIG. 2A. The embodiment of FIGS. 2B and 2C may bedeployed in a similar manner to the embodiment of FIG. 2A.

The system 100 is advanced into the subject's right radial arterythrough an incision in the right arm. The system is advanced through theright subclavian artery 22 and into the innominate artery 12, and aportion of the system is positioned within aortic arch 10. The proximalsheath 110 is retracted proximally to allow proximal filter supportelement 118 to expand to an expanded configuration against the wall ofthe innominate artery 12, as is shown in FIG. 2B. The proximal filterelement 124 is secured either directly or indirectly to support element118 and is therefore reconfigured to the configuration shown in FIG. 2B.The position of distal sheath 112 can be substantially maintained whileproximal sheath is retracted proximally. Once expanded, the proximalfilter assembly 108 filters blood traveling through the innominateartery 12, and therefore filters blood traveling into the right commoncarotid artery 18 and the right vertebral artery 20. The expandedproximal filter assembly 108 is therefore in position to prevent foreignparticles from traveling into the right common carotid artery 18 and theright vertebral artery 20 and into the cerebral vasculature.

The distal sheath 112 is then steered, or bent, and the distal end ofthe distal sheath 112 is advanced into the left subclavian artery 16.The guiding member (not explicitly shown) is thereafter advanceddistally relative to distal sheath 112, allowing the distal supportelement 114 to expand from a collapsed configuration to a deployedconfiguration against the wall of the left subclavian artery 16, asshown in FIG. 2B. Alternatively, or additionally, the distal sheath 112may be proximally retracted to deploy the distal filter assembly 104.The distal filter element 120 is also reconfigured into theconfiguration shown in FIG. 2A. Once expanded, the distal filterassembly 104 filters blood traveling through the left subclavian artery16. The expanded distal filter assembly 104 is therefore in positionedto prevent foreign particles from traveling into the left subclavianartery 16 and the left vertebral artery 24 and into the cerebralvasculature

Once the distal filter assembly 104 has been positioned in the leftsubclavian artery, the distal sheath 112 may be manipulated to thencannulate the left common carotid artery 14. The guiding member (notexplicitly shown) is thereafter advanced distally relative to distalsheath 112, allowing the intermediate support element 116 to expand froma collapsed configuration to a deployed configuration against the wallof the left common carotid artery 14, as shown in FIG. 2C. Theintermediate filter element 122 is also reconfigured into theconfiguration shown in FIG. 2C. Once expanded, the intermediate filterassembly 106 filters blood traveling through the left common carotidartery 14. In some embodiments, the distal filter assembly 104 and theintermediate filter assembly 106 may be deployed prior to the deploymentof the proximal filter assembly 108. The intermediate filter assembly106 is therefore in position to trap foreign particles and prevent themfrom traveling into the cerebral vasculature. As can be seen in FIG. 2C,the protection system 100 traps foreign particles and prevent them fromtraveling into the four arteries 14, 18, 20, 24 that carry oxygenatedblood to the brain.

FIGS. 3A-3C illustrate another illustrative protection device, or filtersystem, 200 in which three filters are delivered with a single deliverydevice. The filter system 200 may be similar to the second filter system60 described above. The filter system 200 may include a distal endregion 202 including at least a first filter assembly 204 (see, forexample, FIG. 3C), a second filter assembly 206, and a third filterassembly 208 (see, for example, FIGS. 3B and 3C and a proximal endregion (not explicitly shown) coupled to a handle (not explicitly shown)configured to remain outside the body. The first filter assembly 204,second filter assembly 206, and third filter assembly 208 may eachinclude a support member or frame 214, 216, 218 and a filter element220, 222, 224 (see, for example, FIG. 3C). The support members 214, 216,218 may be similar in form and function to the support member 31described herein. The filter elements 220, 222, 224 may be similar inform and function to the filter element 33 described herein. In somecases, the handle of the filter system 200 may be similar in form andfunction to the handle 38 described herein. The distal end region 202may include a proximal sheath 210, a proximal shaft (not explicitlyshown) coupled to an expandable proximal, or third, filter assembly 208,a distal shaft 226 coupled to a distal articulatable sheath 212, anintermediate, or second, filter assembly 206, a distal, or first filterassembly 204, and guiding member (not explicitly shown). As can be seen,the filter system 200 may be structurally similar to the second filtersystem 200 described herein and may be similarly arranged. However, inthe filter system 200 illustrated in FIG. 3A, both the second filterassembly 206 and the third filter assembly 208 may be loaded into theproximal sheath 210 for delivery. The second and third filter assemblies206, 208 may be coupled together via a flexible link 228. In some cases,the flexible link 228 may be made having a predetermined shape to betterassist the second filter assembly 206 in cannulation of the left commoncarotid artery 14. It is contemplated that in some instances, theflexible link 228 may be formed as a dual wire system.

The system 200 is advanced into the subject's right radial arterythrough an incision in the right arm, or alternatively through the rightbrachial artery. While not explicitly shown, the system 200 may beadvanced over or in conjunction with one or more guidewires. The systemis advanced through the right subclavian artery 22 and into theinnominate artery 12, and both the distal sheath 212 and a distalportion of the of proximal sheath 210 positioned within the ascendingportion of the aorta 10.

The proximal sheath 210 is retracted proximally to allow intermediatefilter support element 216 to expand to an expanded configuration withinthe aorta 10. The system 200 may then be retracted (e.g., proximallydisplaced) to move the intermediate filter assembly 206 into the leftcommon carotid artery 14, as shown at arrow 230. The predetermined hookshape of the flexible link 228 may help guide the intermediate filterassembly 206 into place. The intermediate support element 216 is movedagainst the wall of the left common carotid artery 14, as shown in FIG.3B. The intermediate filter element 222 is also reconfigured into theconfiguration shown in FIG. 3B. Once expanded, the intermediate filterassembly 206 filters blood traveling through the left common carotidartery 14. In some embodiments, the distal filter assembly 204 and theintermediate filter assembly 206 may be deployed prior to the deploymentof the proximal filter assembly 208. The intermediate filter assembly206 is therefore in position to trap foreign particles and prevent themfrom traveling into the cerebral vasculature

The proximal sheath 210 then be further proximally retracted, as shownat arrow 232, to deploy the proximal filter assembly 208. The positionof distal sheath 212 can be substantially maintained while proximalsheath 210 is retracted proximally. The proximal sheath 210 is retractedproximally to allow proximal filter support element 218 to expand to anexpanded configuration against the wall of the innominate artery 12, asis shown in FIG. 3B, with the flexible link 228 spanning the distancebetween the ostium of the left common carotid artery 14 and theinnominate artery 12. In some cases, the shape and/or curvature of theflexible link 228 may be manipulated by varying the distance theproximal sheath 210 is retracted. The proximal filter element 224 issecured either directly or indirectly to support element 218 and istherefore reconfigured to the configuration shown in FIG. 3B. Onceexpanded, the proximal filter assembly 208 filters blood travelingthrough the innominate artery 12, and therefore filters blood travelinginto the right common carotid artery 18 and the right vertebral artery20. The expanded proximal filter assembly 208 is therefore in positionto prevent foreign particles from traveling into the right commoncarotid artery 18 and the right vertebral artery 20 and into thecerebral vasculature.

The distal sheath 212 is then steered, or bent, and the distal end ofthe distal sheath 212 is advanced into the left subclavian artery 16.The guiding member (not explicitly shown) is thereafter advanceddistally relative to distal sheath 212, allowing the distal supportelement 214 to expand from a collapsed configuration to a deployedconfiguration against the wall of the left subclavian artery 16, asshown in FIG. 3C. Alternatively, or additionally, the distal sheath 212may be proximally retracted to deploy the distal filter assembly 204.The distal filter element 220 is also reconfigured into theconfiguration shown in FIG. 3C. Once expanded, the distal filterassembly 204 filters blood traveling through the left subclavian artery16. The expanded distal filter assembly 204 is therefore in positionedto prevent foreign particles from traveling into the left subclavianartery 16 and the left vertebral artery 24 and into the cerebralvasculature. As can be seen in FIG. 3C, the protection system 200 trapsforeign particles and prevent them from traveling into the four arteries14, 18, 20, 24 that carry oxygenated blood to the brain. It iscontemplated that when the procedure is completed, the insertion stepsmay be performed in reverse to remove the system 200.

FIGS. 4A-4C illustrate another illustrative protection device, or filtersystem, 300 in which three filters are delivered separately. The filtersystem 300 may include steerable sheath 310, a first filter assembly304, a second filter assembly 306 (see, for example, FIG. 4B, and athird filter assembly 308 (see, for example, FIG. 4C), and a proximalend region (not explicitly shown) coupled to a handle (not explicitlyshown) configured to remain outside the body. The first filter assembly304, second filter assembly 306, and third filter assembly 308 may eachinclude a support member or frame 314, 316, 318 and a filter element320, 322, 324 (see, for example, FIG. 3C). The support members 314, 316,318 may be similar in form and function to the support member 31described herein. The filter elements 320, 322, 324 may be similar inform and function to the filter element 33 described herein. In somecases, the handle of the filter system 300 may be similar in form andfunction to the handle 38 described herein.

The steerable sheath 310 is advanced into the subject's right radialartery through an incision in the right arm, or alternatively throughthe right brachial artery. While not explicitly shown, the system 300may be advanced over or in conjunction with one or more guidewires. Thesheath 310 is advanced through the right subclavian artery 22 and intothe innominate artery 12, the arch of aorta 10 to a site proximate theostium of the left subclavian artery 16 (if not actually cannulatingleft subclavian artery 16). The first filter assembly 304 may then beadvanced through a lumen of the sheath 310. Alternately, the firstfilter assembly 304 may be pre-loaded within the sheath 310 and advancedtherewith. The filter assembly 304 may be distally advanced from thesheath 310 (or the sheath 310 proximally retracted) to allow the distalfilter support element 314 to expand from a collapsed configuration to adeployed configuration against the wall of the left subclavian artery16, as shown in FIG. 4A. The distal filter element 320 is alsoreconfigured into the configuration shown in FIG. 4A. Once expanded, thedistal filter assembly 304 filters blood traveling through the leftsubclavian artery 16. The expanded distal filter assembly 304 istherefore in positioned to prevent foreign particles from traveling intothe left subclavian artery 16 and the left vertebral artery 24 and intothe cerebral vasculature.

After placement of the first filter assembly 304, the sheath 310completely withdrawn from the patient such that the filter wire 330(similar in form and function to filter wire 52 b described herein) isfree from the sheath 310. The steerable sheath 310 is then advanced intothe subject's right radial artery through the incision in the right arm.The sheath 310 is advanced through the right subclavian artery 22 andinto the innominate artery 12, the arch of aorta 10 to a site proximatethe ostium of the left common carotid artery 14 (if not actuallycannulating left common carotid artery 30). The second filter assembly306 may then be advanced through a lumen of the sheath 310. Alternately,the second filter assembly 306 may be pre-loaded within the sheath 310and advanced therewith. The filter assembly 306 may be distally advancedfrom the sheath 310 (or the sheath 310 proximally retracted) to allowthe intermediate filter support element 316 to expand from a collapsedconfiguration to a deployed configuration against the wall of the leftcommon carotid artery 14, as shown in FIG. 4B. The intermediate filterelement 322 is also reconfigured into the configuration shown in FIG.4B. Once expanded, the intermediate filter assembly 306 filters bloodtraveling through the left common carotid artery 14. The intermediatefilter assembly 306 is therefore in position to trap foreign particlesand prevent them from traveling into the cerebral vasculature.

After placement of the second filter assembly 306, the sheath 310 isagain completely withdrawn from the patient such that a second filterwire 332 (similar in form and function to filter wire 52 b describedherein) is free from the sheath 310. The steerable sheath 310 is thenadvanced into the subject's right radial artery through the incision inthe right arm. The sheath 310 is advanced through the right subclavianartery 22 and into the innominate artery 12. The third filter assembly308 may then be advanced through a lumen of the sheath 310. Alternately,the third filter assembly 308 may be pre-loaded within the sheath 310and advanced therewith. The filter assembly 308 may be distally advancedfrom the sheath 310 (or the sheath 310 proximally retracted) to allowthe proximal filter support element 318 to expand from a collapsedconfiguration to a deployed configuration against the wall of theinnominate artery 12, as shown in FIG. 4C. The proximal filter element324 is also reconfigured into the configuration shown in FIG. 4C andfilters blood traveling through the innominate artery 12, and thereforefilters blood traveling into the right common carotid artery 18 and theright vertebral artery 20. The expanded proximal filter assembly 308 istherefore in position to prevent foreign particles from traveling intothe right common carotid artery 18 and the right vertebral artery 20 andinto the cerebral vasculature. After placement of the third filterassembly 308, the sheath 310 is again completely withdrawn from thepatient such that a third filter wire (not explicitly shown) (similar inform and function to filter wire 52 b described herein) is free from thesheath 310. As can be seen in FIG. 4C, the protection system 300 trapsforeign particles and prevent them from traveling into the four arteries14, 18, 20, 24 that carry oxygenated blood to the brain. It iscontemplated that when the procedure is completed, the insertion stepsmay be performed in reverse to remove the system 300.

FIG. 5 illustrates another illustrative protection device, or filtersystem 400 in which two filters may be utilized to protect all fourarteries 14, 18, 20, 24 that carry oxygenated blood to the brain. Thefilter system 400 may include an inner sheath 402, an outer sheath 404,a first, or distal, filter assembly 406, a second, or proximal, filterassembly 408, and a proximal end region (not explicitly shown) coupledto a handle (not explicitly shown) configured to remain outside thebody. In some embodiments, one or both of the inner sheath 402 and theouter sheath 404 may be steerable. The first filter assembly 406 and thesecond filter assembly 408 may each include a support member or frame410, 412 and a filter element 414, 416. The support members 410, 412 maybe similar in form and function to the support member 31 describedherein. The filter elements 414, 416 may be similar in form and functionto the filter element 33 described herein. The second filter assembly408 may be configured to over the ostium of the both the innominateartery 12 and the left common carotid artery 14. In some cases, thehandle of the filter system 400 may be similar in form and function tothe handle 38 described herein.

The filter system 400 may be advanced into the subject's right radial(or alternatively, the right brachial) artery through an incision in theright arm. While not explicitly shown, the system 400 may be advancedover or in conjunction with one or more guidewires. The system 400 isadvanced through the right subclavian artery 22 and into the innominateartery 12 until the distal end 418 of the outer sheath 404 is adjacentto the ostium 420 of the innominate artery 12. The outer sheath 404 maythen be proximally retracted to deploy the proximal filter assembly 408over the ostia 420, 422 of the innominate and left common carotidarteries 12, 14. As can be seen, the support member 412 and the filterelement 416 of the proximal filter assembly 408 may be sized and shapedto extend over both the ostia 420, 422 of the innominate and left commoncarotid arteries 12, 14. The inner sheath 402 may then be distallyadvanced toward and, sometimes through, the ostium 424 of the leftsubclavian artery 16. The inner sheath 402 may be proximally retractedto deploy the distal filter assembly 406 within the left subclavianartery 16. Alternatively, the order in which the filter assemblies 406,408 are deployed may be reversed. It is contemplated that when theprocedure is completed, the insertion steps may be performed in reverseto remove the system 500.

FIG. 6A illustrates another illustrative protection device, or filtersystem 500 in which a deflector 504, a distal filter assembly 506, and aproximal filter assembly 508 may be utilized to protect all fourarteries 14, 18, 20, 24 that carry oxygenated blood to the brain. Thefilter system 500 may similar in form and function to the filter system100 described above. The filter system 500 may include a distal endregion 502 including at least a deflector 504, a distal filter assembly506, and a proximal filter assembly 508 and a proximal end region (notexplicitly shown) coupled to a handle (not explicitly shown) configuredto remain outside the body. The deflector 504, distal filter assembly506, and proximal filter assembly 508 may each include a support memberor frame 514, 516, 518 and a filter element 520, 522, 524. The supportmembers 514, 516, 518 may be similar in form and function to the supportmember 31 described herein. The filter elements 520, 522, 524 may besimilar in form and function to the filter element 33 described herein.However, the deflector 504 may have a generally planar shape such thatforeign particulates are not necessarily trapped within the filterelement 520 as the deflector is removed. However, the structure of thedeflector 504 may be such that blood flow removed any foreignparticulates away from the ostium of the left subclavian artery 16 toreduce the likelihood of a foreign particulate entering the leftvertebral artery 24. In some cases, the handle of the filter system 500may be similar in form and function to the handle 38 described herein.

The distal end region 502 may include a proximal sheath 510, a proximalshaft (not explicitly shown) coupled to an expandable proximal filterassembly 508, a distal shaft (not explicitly shown) coupled to a distalarticulatable sheath 512, a proximal filter assembly 506, a deflector504, and guiding member (not explicitly shown). As can be seen, thefilter system 500 may be structurally similar to the second filtersystem 60 and/or the filter system 100 described herein and may besimilarly arranged. However, in the filter system 500 illustrated inFIG. 6A, both the deflector 504 and the distal filter assembly 506 maybe loaded into the distal sheath 512 for delivery. The deflector and thedistal filter assembly 504, 506 may be coupled together via a wire ortether 526. In some cases, the tether 526 may be made have apredetermined shape to better assist the tether 526 in seating andspanning the distance from the ostium of the left subclavian artery 16to the left common carotid artery 14.

The system 500 is advanced into the subject's right radial arterythrough an incision in the right arm, or alternatively through the rightbrachial artery. While not explicitly shown, the system 500 may beadvanced over or in conjunction with one or more guidewires. The systemis advanced through the right subclavian artery 22 and into theinnominate artery 12, and a portion of the system is positioned withinaortic arch 10. The proximal sheath 510 is retracted proximally to allowproximal filter support element 518 to expand to an expandedconfiguration against the wall of the innominate artery 12, as is shownin FIG. 6A. The proximal filter element 524 is secured either directlyor indirectly to support element 518 and is therefore reconfigured tothe configuration shown in FIG. 6A. The position of distal sheath 512can be substantially maintained while proximal sheath is retractedproximally. Once expanded, the proximal filter assembly 508 filtersblood traveling through the innominate artery 12, and therefore filtersblood traveling into the right common carotid artery 18 and the rightvertebral artery 20. The expanded proximal filter assembly 508 istherefore in position to prevent foreign particles from traveling intothe right common carotid artery 18 and the right vertebral artery 20 andinto the cerebral vasculature.

The distal sheath 512 is then steered, or bent, and the distal end ofthe distal sheath 512 is advanced into the left common carotid artery14. The guiding member (not explicitly shown) is thereafter advanceddistally relative to distal sheath 512, allowing the deflector 504 andthe distal filter assembly 506 to be discharged from the distal end ofthe distal sheath 512. The pre-formed tether 526 may position thedeflector proximate the ostium of the left subclavian artery 16 whilethe distal filter assembly 506 is positioned in the left common carotidartery 14. As the distal filter assembly is deployed, the distal supportelement 516 expands from a collapsed configuration to a deployedconfiguration against the wall of the left common carotid artery 14, asshown in FIG. 6A. The distal filter element 522 is also reconfiguredinto the configuration shown in FIG. 6A. Once expanded, the distalfilter assembly 506 filters blood traveling through the left commoncarotid artery 14. Similarly, the deflector support element 514 expandsfrom a collapsed configuration to a deployed configuration against thewall of the left subclavian artery 16, as shown in FIG. 6A. Thedeflector filter element 520 is also reconfigured into the configurationshown in FIG. 6A. Once expanded, the deflector 504 filters bloodtraveling through the left subclavian artery 16. The distal filterassembly 506 is therefore in position to trap foreign particles andprevent them from traveling into the cerebral vasculature and theexpanded deflector 504 is in positioned to prevent foreign particlesfrom traveling into the left subclavian artery 16 and the left vertebralartery 24 and into the cerebral vasculature.

It is contemplated that the deflector 504 may not be coupled or linkedto the distal filter assembly 506 via the tether 526 (e.g., the tether526 is not present in the system 500). In such an instance, thedeflector 504 may include a deflector wire 528 a, 528 b. It iscontemplated that the deflector is provided with only a single wire 528a or 528 b. However, the deflector wire 528 a may be positioned outsideof the distal sheath 512 (and in some cases, also outside of theproximal sheath 510). In other embodiments, the deflector wire 528 b maybe disposed within a lumen of the distal sheath 512 and/or the proximalsheath 510.

In some embodiments, the deflector 504 and the distal filter assembly506 may be deployed prior to the deployment of the proximal filterassembly 508. It is contemplated that when the procedure is completed,the insertion steps may be performed in reverse to remove the system500. As can be seen in FIG. 6A, the protection system 500 traps foreignparticles and prevent them from traveling into the four arteries 14, 18,20, 24 that carry oxygenated blood to the brain.

FIG. 6B illustrates an alternative embodiment of the illustrativeprotection system 500 of FIG. 6A where the distal filter assembly 506has been replaced with a spring-loaded filter assembly 540. Thespring-loaded filter assembly 540 may include a spring-loaded expandableframe 542 and a filter element 544. The spring-loaded expandable frame542 may have a resiliency or compressibility that allows thespring-loaded filter assembly 540 to be deployed within the aorta 10 andsubsequently guided into the left common carotid artery 14. The filterelement 544 may be similar in form and function to the filter element 33described herein.

In the embodiment of FIG. 6B, the system 500 is advanced into thesubject's right radial artery through an incision in the right arm, oralternatively through the right brachial artery. While not explicitlyshown, the system 500 may be advanced over or in conjunction with one ormore guidewires. The system is advanced through the right subclavianartery 22 and into the innominate artery 12, and a portion of the systemmay positioned within aortic arch 10. The deflector 504 and thespring-loaded filter assembly 540 may be distally advanced from thedistal end of the distal sheath 512 in the aorta 10. The articulabledistal sheath 512 may then be manipulated to cannulate the left commoncarotid artery 14 thereby deploying the spring-loaded filter assembly540 in the left common carotid artery 14 and the deflector 504 acrossthe left subclavian artery 16. The proximal sheath 510 may then beretracted to deploy the proximal filter assembly 508. As can be seen inFIG. 6A, the protection system 500 traps foreign particles and preventthem from traveling into the four arteries 14, 18, 20, 24 that carryoxygenated blood to the brain. It is contemplated that when theprocedure is completed, the insertion steps may be performed in reverseto remove the system 500.

FIG. 7A illustrates another illustrative protection device 600, orfilter system in which a single, oversized filter assembly 604 coversthe ostia of the left subclavian, left common carotid and innominatearteries 16, 14, 12, which conforming to the curve of the aortic arch10. Referring additionally to FIG. 7B, which illustrates a schematicview of the filter assembly 604 outside of the body, the filter assembly604 may include an expandable frame 606 (which may be similar in formand function to the support member 31 described herein), a porous filtermaterial 608 (which may be similar in form and function to the filterelement 33 described herein), one or more deployment wires 610, 612 andone or more pull wires 614, 616. The deployment wires 610, 612 may beactuated to exert a force on the frame 606 to shift or bias the filterassembly 604 off axis (shown at arrow 618). The deployment wires 610,612 may be configured to extend through a lumen of a delivery sheath 602to a point outside the body where the deployment wires 610, 612 can bemanipulated by a user. The pull wires 614, 616 may be actuated to exerta force on the frame 606 to help conform the frame 606 to the uppercurve of the aortic arch 10 ((shown at arrow 620). In this manner, notonly are all cerebral arteries 14, 18, 20, 24 protected but the filterassembly 604 may not interfere with medical devices, catheters, etc.,being passed through the aortic arch 10.

The system 600 is advanced into the subject's right radial arterythrough an incision in the right arm, or alternatively through the rightbrachial artery. While not explicitly shown, the system 600 may beadvanced over or in conjunction with one or more guidewires. The systemis advanced through the right subclavian artery 22 and into theinnominate artery 12, and a portion of the system may positioned withinaortic arch 10. The filter assembly 604 may be distally advanced fromthe distal end of the guide sheath 602 and partially into the aorta 10.The deployment wires 610, 612 and/or the pull wires 614, 616 may then bemanipulated to position the filter assembly 604 in the desiredorientation, such that the filter assembly 604 covers the ostia of theleft subclavian, left common carotid and innominate arteries 16, 14, 12.The guide sheath 602 may then be retracted or left within thevasculature during the remainder of the procedure. As can be seen inFIG. 7A, the protection system 600 traps (and/or deflects) foreignparticles and prevents them from traveling into the four arteries 14,18, 20, 24 that carry oxygenated blood to the brain. It is contemplatedthat when the procedure is completed, the insertion steps may beperformed in reverse to remove the system 6

FIG. 7C illustrates another illustrative protection device 700, orfilter system in which a single, oversized filter assembly 704 coversthe ostia of the left subclavian, left common carotid and innominatearteries 16, 14, 12, which conforming to the curve of the aortic arch10. The filter assembly 704 may include an expandable frame 706 (whichmay be similar in form and function to the support member 31 describedherein) and a porous filter material 708 (which may be similar in formand function to the filter element 33 described herein). The filtermaterial 708 may include a first shaped section 710, a second shapedsection 712, and a third shaped sections 714 configured to prolapse intothe left subclavian, left common carotid, and innominate arteries 16,14, 12, respectively. FIG. 7D illustrates a magnified view of the secondshaped section 712. While FIG. 7D is described with respect to thesecond shaped section 712, the first and third shaped sections 710, 714may be similarly formed. In some embodiments, the shaped section 712 canbe laser drilled, creating holes allowing blood 716 to pass whilefiltering debris. In some cases, the hole spacing can be denser at thetop 718 a of the shaped section 712 and become less dense as it nearsthe end 718 b adjacent to the ostia. However, this is not required. Whenso provided, the denser holes at the top 718 a of the shaped section 712can cause an increased resistance to blood flow in the area of theshaped section nearer the ostia 718 b and, conversely, decreasedresistance to blood flow out of the shaped sections 718 a whereincreased flow is needed. The areas, near the ostia, 718 b whereresistance to flow is increased may create better wall apposition thusreducing risk of debris passing between the membrane 708 and the ostiaof the left subclavian, left common carotid and innominate arteries 16,14, 12. This selective resistance to blood flow may create effectivesealing without comprising filtering.

The system 700 is advanced into the subject's right radial arterythrough an incision in the right arm, or alternatively through the rightbrachial artery. While not explicitly shown, the system 700 may beadvanced over or in conjunction with one or more guidewires. The systemis advanced through the right subclavian artery 22 and into theinnominate artery 12, and a portion of the system may positioned withinaortic arch 10. The filter assembly 704 may be distally advanced fromthe distal end of the guide sheath 702 and partially into the aorta 10.The filter assembly 704 may be manipulated such that it covers the ostiaof the left subclavian, left common carotid and innominate arteries 16,14, 12. In some cases, the filter assembly 704 may include deploymentwires and/or pull wires similar to those described with respect to FIGS.7A and 7B to facilitate placement of the filter assembly 704. The guidesheath 702 may then be retracted or left within the vasculature duringthe remainder of the procedure. As can be seen in FIG. 7A, theprotection system 700 traps (and/or deflects) foreign particles andprevents them from traveling into the four arteries 14, 18, 20, 24 thatcarry oxygenated blood to the brain. It is contemplated that when theprocedure is completed, the insertion steps may be performed in reverseto remove the system 700.

While the methods and devices described herein may be susceptible tovarious modifications and alternative forms, specific examples thereofhave been shown in the drawings and are described in detail herein. Itshould be understood, however, that the inventive subject matter is notto be limited to the particular forms or methods disclosed, but, to thecontrary, covers all modifications, equivalents, and alternativesfalling within the spirit and scope of the various implementationsdescribed and the appended claims. Further, the disclosure herein of anyparticular feature, aspect, method, property, characteristic, quality,attribute, element, or the like in connection with an implementation orembodiment can be used in all other implementations or embodiments setforth herein. In any methods disclosed herein, the acts or operationscan be performed in any suitable sequence and are not necessarilylimited to any particular disclosed sequence and not be performed in theorder recited. Various operations can be described as multiple discreteoperations in turn, in a manner that can be helpful in understandingcertain embodiments; however, the order of description should not beconstrued to imply that these operations are order dependent.Additionally, the structures described herein can be embodied asintegrated components or as separate components. For purposes ofcomparing various embodiments, certain aspects and advantages of theseembodiments are described. Not necessarily all such aspects oradvantages are achieved by any particular embodiment. Thus, for example,embodiments can be carried out in a manner that achieves or optimizesone advantage or group of advantages without necessarily achieving otheradvantages or groups of advantages. The methods disclosed herein mayinclude certain actions taken by a practitioner; however, the methodscan also include any third-party instruction of those actions, eitherexpressly or by implication. For example, actions such as “deploying aself-expanding filter” include “instructing deployment of aself-expanding filter.” The ranges disclosed herein also encompass anyand all overlap, sub-ranges, and combinations thereof. Language such as“up to,” “at least,” “greater than,” “less than,” “between,” and thelike includes the number recited. Numbers preceded by a term such as“about” or “approximately” include the recited numbers and should beinterpreted based on the circumstances (e.g., as accurate as reasonablypossible under the circumstances, for example ±5%, ±10%, ±15%, etc.).For example, “about 7 mm” includes “7 mm.” Phrases preceded by a termsuch as “substantially” include the recited phrase and should beinterpreted based on the circumstances (e.g., as much as reasonablypossible under the circumstances). For example, “substantially straight”includes “straight.”

Those skilled in the art will recognize that the present invention maybe manifested in a variety of forms other than the specific embodimentsdescribed and contemplated herein. Accordingly, departure in form anddetail may be made without departing from the scope and spirit of thepresent invention as described in the appended claims.

What is claimed is:
 1. A method of inhibiting embolic material fromentering cerebral vasculature, the method comprising: positioning aguidewire through a right subclavian artery and into a left subclavianartery; tracking a distal portion of a first protection device over theguidewire, the distal portion of the first protection device comprising:an outer sheath; a first self-expanding filter assembly radially withinthe outer sheath; and at least one of proximally retracting the outersheath and distally advancing the self-expanding filter assembly todeploy the first self-expanding filter assembly from the outer sheath inthe left subclavian artery upstream of the left vertebral artery; afterdeploying the self-expanding filter assembly, withdrawing the outersheath from the right subclavian artery and withdrawing the guidewireinto an innominate artery; tracking a distal portion of a secondprotection device over the guidewire, the distal portion of the secondprotection device comprising: a proximal sheath; a proximalself-expanding filter assembly radially within the proximal sheath; adistal sheath; and a distal self-expanding filter assembly radiallywithin the distal sheath; at least one of proximally retracting theproximal sheath and distally advancing the proximal self-expandingfilter assembly to deploy the proximal self-expanding filter assemblyfrom the proximal sheath in the innominate artery; steering the distalsheath into a left common carotid artery; at least one of proximallyretracting the distal sheath and distally advancing the distalself-expanding filter assembly to deploy the distal self-expandingfilter assembly from the distal sheath in the left common carotidartery; and after deploying the proximal and distal self-expandingfilter assemblies, withdrawing the proximal and distal sheaths.
 2. Themethod of claim 1, wherein the first protection device and the secondprotection device are inserted into a right radial artery or a rightbrachial artery through a same incision.
 3. The method of claim 1,further comprising performing an endovascular procedure, the deployedfirst, proximal, and distal filter assemblies inhibiting embolicmaterial from entering cerebral vasculature through the left vertebralartery, a right common carotid artery, a right vertebral artery and theleft common carotid artery during the endovascular procedure.
 4. Themethod of claim 3, further comprising after performing the endovascularprocedure, withdrawing the first, proximal, and distal filterassemblies.
 5. The method of claim 1, wherein the first protectiondevice further comprises an inner member radially inward of the outersheath.
 6. The method of claim 1, further comprising measuring anarterial pressure using one of the first and second protection devices.7. The method of claim 1, wherein the first protection device furthercomprises a filter wire coupled to a proximal end of the firstself-expanding filter and extending distally therefrom.
 8. The method ofclaim 7, wherein an entirety of a length of the second protection deviceis tracked over the filter wire.
 9. The method of claim 7, wherein lessthan an entirety of a length of the second protection device is trackedover the filter wire.
 10. The method of claim 9, wherein the secondprotection device further comprises a rapid exchange port.
 11. A methodof inhibiting embolic material from entering cerebral vasculature, themethod comprising: positioning a guidewire through a right subclavianartery and into a left subclavian artery; tracking a distal portion of afirst protection device over the guidewire, the distal portion of thefirst protection device comprising: an outer sheath; an inner memberradially inward of the outer sheath, the inner member comprising aguidewire lumen; and a first self-expanding filter assembly radiallybetween the outer sheath and the inner member, the first self-expandingfilter assembly having an opening facing a proximal end of the outersheath; at least one of proximally retracting the outer sheath anddistally advancing the self-expanding filter assembly to deploy thefirst self-expanding filter assembly from the outer sheath in the leftsubclavian artery upstream of the left vertebral artery; after deployingthe self-expanding filter assembly, withdrawing the outer sheath fromthe right subclavian artery and withdrawing the guidewire into aninnominate artery; tracking a distal portion of a second protectiondevice over the guidewire, the distal portion of the second protectiondevice comprising: a proximal sheath; a proximal self-expanding filterassembly radially within the proximal sheath; an articulatable distalsheath; and a distal self-expanding filter assembly radially within thedistal sheath; at least one of proximally retracting the proximal sheathand distally advancing the proximal self-expanding filter assembly todeploy the proximal self-expanding filter assembly from the proximalsheath in the innominate artery; steering the distal sheath into a leftcommon carotid artery; at least one of proximally retracting the distalsheath and distally advancing the distal self-expanding filter assemblyto deploy the distal self-expanding filter assembly from the distalsheath in the left common carotid artery; and after deploying theproximal and distal self-expanding filter assemblies, withdrawing theproximal and distal sheaths.
 12. The method of claim 11, wherein thefirst protection device and the second protection device are insertedinto a right radial artery or a right brachial artery through a sameincision.
 13. The method of claim 11, further comprising performing anendovascular procedure, the deployed first, proximal, and distal filterassemblies inhibiting embolic material from entering cerebralvasculature through the left vertebral artery, a right common carotidartery, a right vertebral artery and the left common carotid arteryduring the endovascular procedure.
 14. The method of claim 13, furthercomprising after performing the endovascular procedure, withdrawing thefirst, proximal, and distal filter assemblies.
 15. A method ofinhibiting embolic material from entering cerebral vasculature, themethod comprising: positioning a guidewire in a first artery; tracking adistal portion of a first protection device over the guidewire, thedistal portion of the first protection device comprising: a proximalsheath; a proximal self-expanding filter assembly radially within theproximal sheath; a distal sheath; a distal self-expanding filterassembly radially within the distal sheath; and an intermediateself-expanding filter assembly radially within the distal sheath; atleast one of proximally retracting the proximal sheath and distallyadvancing the proximal self-expanding filter assembly to deploy theproximal self-expanding filter assembly from the proximal sheath in thefirst artery; steering the distal sheath into a second artery; at leastone of proximally retracting the distal sheath and distally advancingthe distal self-expanding filter assembly to deploy the distalself-expanding filter assembly from the distal sheath in the secondartery; steering the distal sheath into a third artery; at least one ofproximally retracting the distal sheath and distally advancing theintermediate self-expanding filter assembly to deploy the distalself-expanding filter assembly from the distal sheath in the thirdartery; and after deploying the proximal, distal, and intermediateself-expanding filter assemblies, withdrawing the proximal and distalsheaths.
 16. The method of claim 15, wherein the first protection deviceis inserted into a right radial artery or a right brachial artery. 17.The method of claim 15, further comprising performing an endovascularprocedure, the deployed proximal, intermediate, and distalself-expanding filter assemblies inhibiting embolic material fromentering cerebral vasculature through the left vertebral artery, a rightcommon carotid artery, a right vertebral artery and the left commoncarotid artery during the endovascular procedure.
 18. The method ofclaim 17, further comprising after performing the endovascularprocedure, withdrawing the proximal, intermediate, and distal filterassemblies.
 19. The method of claim 15, wherein the first protectiondevice further comprises a tether extending between the distalself-expanding filter assembly and the intermediate self-expandingfilter assembly.
 20. The method of claim 19, wherein the tether has apreformed shape configured to guide the intermediate filter assemblytowards the third artery.